3
Cost-Effectiveness Analysis

The assessment of cost-effectiveness depends on measuring the effectiveness along with the cost of an intervention. The most useful application of cost-effectiveness analysis is to compare alternative interventions in terms of a given level of a particular effect. One of the complicating factors in cost-effectiveness analysis is that an intervention (e.g., raising the level of vitamin C fortification) may have several effects; it may be highly cost-effective for some of these effects but not others. Cost-effectiveness analysis cannot help assess which effect should be given priority.

Effectiveness

Measures of effectiveness depend on the objectives of a project. The current pilot project implicitly identifies two objectives: (1) to improve or maintain the vitamin C status of the target (beneficiary) population and (2) improve or maintain the iron status of the population by providing vitamin C to enhance iron absorption. It is assumed that accomplishing these will achieve the congressionally mandated objective of improving the health of food aid recipients, thereby reducing the need for, and cost of, later medical interventions. The first objective, improving or maintaining the vitamin C intake of the target population, seems to consist of two subobjectives: (1) to cure scurvy in populations where the deficiency disease is present and (2) to prevent its occurrence by ensuring the dietary sufficiency of vitamin C.

A secondary objective is to improve the iron status of the target population. The implicit assumption is that adding additional vitamin C to corn-soy blend (CSB) or wheat-soy blend (WSB) is an appropriate way to achieve this objective. Cost-effectiveness assessment ideally would compare the chosen pilot



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--> 3 Cost-Effectiveness Analysis The assessment of cost-effectiveness depends on measuring the effectiveness along with the cost of an intervention. The most useful application of cost-effectiveness analysis is to compare alternative interventions in terms of a given level of a particular effect. One of the complicating factors in cost-effectiveness analysis is that an intervention (e.g., raising the level of vitamin C fortification) may have several effects; it may be highly cost-effective for some of these effects but not others. Cost-effectiveness analysis cannot help assess which effect should be given priority. Effectiveness Measures of effectiveness depend on the objectives of a project. The current pilot project implicitly identifies two objectives: (1) to improve or maintain the vitamin C status of the target (beneficiary) population and (2) improve or maintain the iron status of the population by providing vitamin C to enhance iron absorption. It is assumed that accomplishing these will achieve the congressionally mandated objective of improving the health of food aid recipients, thereby reducing the need for, and cost of, later medical interventions. The first objective, improving or maintaining the vitamin C intake of the target population, seems to consist of two subobjectives: (1) to cure scurvy in populations where the deficiency disease is present and (2) to prevent its occurrence by ensuring the dietary sufficiency of vitamin C. A secondary objective is to improve the iron status of the target population. The implicit assumption is that adding additional vitamin C to corn-soy blend (CSB) or wheat-soy blend (WSB) is an appropriate way to achieve this objective. Cost-effectiveness assessment ideally would compare the chosen pilot

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--> intervention with alternatives (e.g., raising the iron fortification level; changing the type of iron used). However, reviewing iron fortification levels was not part of this committee's task. Both objectives of the pilot study involve improving the micronutrient status of a target population. The benefit to be gained from the project depends on raising the population from a state of vitamin C deficiency to a state of vitamin C sufficiency. There is no benefit to be gained from raising the population's intake or absorption of a nutrient if the amount is already satisfactory. Thus, the measures of effectiveness depend not only on the success of nutrient delivery to, and consumption by, a target population but also on the previous status of the population. U.S. food aid is used for two purposes: developmental aid and emergency relief. Approximately 88 percent of U.S.-supplied fortified, blended food is used for developmental purposes. Developmental aid uses food primarily in school feeding programs, maternal and child health (MCH) programs, and food-for-work projects where the food is used as a substitute for money to pay for labor on development projects. Developmental food aid is rarely the sole source of food for a family, and since there is no evidence of vitamin C deficiency in populations receiving this type of food aid there is no rationale for increasing vitamin C in food aid commodities for this purpose. Many recipients of developmental food aid are iron deficient (OMNI, 1994; Toole, 1994; Beaton, 1995). However, doubling the vitamin C content of fortified, blended foods to improve iron absorption may be much less cost-effective than increasing the iron content of such foods above their present levels of fortification, or of increasing iron in the diet by other means. Research data to support either intervention are insufficient. Emergency relief food aid is distributed to refugees and other distressed populations (famine sufferers or other displaced populations) in camps. A small proportion of refugee populations has been shown to be vitamin C deficient when unfortified food was given (Ranum and Chomé, 1997). All of these populations were in the eastern Sahel (greater Horn of Africa and Kenya). Except for some recent reports of Bhutanese refugees in Nepal, no other refugee populations have shown documented evidence of vitamin C deficiency, including many others in the rest of Africa. If the proposal under consideration is to increase the fortification levels of vitamin C in all CSB and WSB, then the cost of such an intervention must be measured against the small number of beneficiaries who are actually in need of the nutrient. For any project of a given size and cost, the cost-effectiveness is lower (that is, better) if the proportion of the population in need is higher. The cost-effectiveness analysis uses as a basis for comparison the nutrient content of blended foods at present levels of fortification that could not be purchased under the Public Law (P.L.) 480 Title II program because the money was spent increasing the vitamin C fortification. This is a conservative basis for comparison because the nutrient content of other usual food aid commodities

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--> that could not be bought would be many times greater, resulting in analyses that are much less favorable to increased fortification. Although this analysis is based on the assumption of a fixed dollar amount available for purchase of blended foods, the results are not dependent on this assumption because the same principles apply to any increases in funding that might be allocated specifically to increased vitamin C fortification instead of increased food aid. Although outbreaks of scurvy in refugee populations are a concern, both inadequate food intake (in part alleviated by the blended commodities) and a high prevalence of other micronutrient deficiencies are also common problems. For example, deficiencies of niacin, iron, vitamin A, and iodine also occur in these populations (OMNI, 1994; Toole, 1994). Thus, the benefits of increased expenditures on vitamin C have to be viewed in the context of asking why adding more of this nutrient is more important than supplementing with other nutrients or simply increasing the total amount of blended, fortified food provided. Vitamin C Objective Scurvy has not been documented among stable, free-living populations that are the typical target group for development projects, except in extreme situations of famine. Scurvy has been documented in a small proportion of refugee camps in the greater Horn of Africa. It was found only under the most adverse conditions: isolated camps entirely dependent on food aid rations, with no possibility of trade or exchange with local markets and with no time to grow their own foods or adapt to the local situation. Three outbreaks have occurred in this high risk area (Kenya, Ethiopia, Sudan) since the World Food Programme (WFP) and the United Nations High Commissioner for Refugees (UNHCR) adopted the policy in 1994 of providing fortified, blended foods to populations wholly dependent on food aid. Other risk factors for scurvy include physiological status (pregnancy and lactation), and, in some cases, length of time traveling to a camp and conditions during transit. This describes only a small proportion of all the refugees in camps in which rations are provided; many have access to local indigenous markets, and some camps have provision for refugees growing small amounts of food themselves. Food rations delivered in development programs (e.g., MCH supplementary feeding, school feeding, etc.) are intended as supplements, not as complete diets. In these free-living populations, access to markets and/or home-produced food is a given assumption. Vitamin C deficiency has rarely been reported in such populations.

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--> Iron Objective The same considerations apply to iron. Iron deficiency has been far more widely documented as a nutritional problem than scurvy, both in the artificial environment of refugee camps and in the low-income, free-living populations that would be the beneficiaries of developmental food aid. In terms of this objective, the question for cost-effectiveness analysis is whether adding vitamin C to the diet through CSB and WSB is the most cost effective way to achieve improved iron status. Cost Cost-effectiveness analysis typically considers all the costs involved in a given intervention, including (for food distribution) raw materials, processing, transport, and the labor of people involved in the distribution and preparation of the food. For example, if a food required additional preparation time, the cost of that time (although not an accounting cost to the project) would be included. If all CSB and WSB were fortified with vitamin C at the higher level, the food would be handled, transported, stored, distributed, and prepared in exactly the same way as before; only the additional cost of vitamin C in the premix would be considered a program cost. There are no side effects from high doses of vitamin C even at the maximum intakes possible if fortification levels are doubled. Thus the cost of potential side effects does not have to be taken into account. According to the Sharing United States Technology to Aid in the Improvement of Nutrition (SUSTAIN) report (Ranurn and Chomé, 1997), the U.S. Agency for International Development (USAID) considers it operationally very difficult for the U.S. P.L. 480 program to add extra vitamin C to only some of the CSB or WSB in the program and then to target the blends containing extra fortification toward emergency populations identified as likely to benefit. There is also a considerable lag time involved in procuring and shipping such special foods, typically 4 to 6 months (see Boxes 4-1, 4-2). If this lag time cannot be reduced, the provision of specially prepared, high vitamin C blended foods is an inappropriate response to emergency needs for additional vitamin C, although it may be appropriate when the risk of low vitamin C intake continues. The cost-effectiveness assessment would be affected if it were possible to fortify a small percentage of blended food and target this food specifically to refugee situations known to be at high risk of vitamin C deficiency over the long run. Cost-effectiveness would be improved because the additional fortification would be required only for the small percentage of blended food going to the high-risk population; however, there would be some additional management cost involved in keeping track of two separate supplies of blended food. Those responsible for such commodities at USAID's Bureau of Humanitarian Response (BHR) suggested that this would be quite difficult to do.

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--> Cost-Effectiveness Estimate Vitamin C Objective The objective of raising blended foods' fortification levels is to avert vitamin C deficiency or scurvy. Thus, the proper measure of cost-effectiveness is the cost per case of scurvy averted. For food relief programs, the recommended daily allowance of vitamin C is 30 mg (FAO/WHO, 1974) but the majority of references cited in this report (Barker et al., 1971; Hodges et al., 1969, 1971) state that an intake of 6–10 mg per day is sufficient to prevent the appearance of symptoms of vitamin C deficiency in a population. The cost per case of scurvy averted could not be measured directly. There have been no representative studies of scurvy incidence or prevalence in refugee populations, only anecdotal reports and localized (single camp) surveys of scurvy outbreaks in particular locations. The following analysis is based on the assumptions spelled out in the text and is in this sense a hypothetical ''best guess.'' The conclusion is that using the most optimistic assumptions, the cost of using highly fortified CSB to avert a case of scurvy may range from $158 to $1,223, depending entirely on assumptions regarding coverage of the target population, while the cost to avert a case of scurvy by tripling the conventional ration may range from 7.45 to $74.50 based on the expectation that rations would be targeted by camp, but not by individual within a camp. Thus increasing the conventional ration to high-risk camps is at least 2.1 times more cost-effective than increasing the level of fortification and may be 16.4 times as cost-effective or more. Assumptions Regarding Proportion of Beneficiaries at Risk of Vitamin C Deficiency and Scurvy: Size of the Target Population The objective of the project is not to deliver vitamin C; it is to avert vitamin C deficiency, specifically scurvy. Delivery of vitamin C to populations already sufficient in vitamin C is a waste. Although the possibility always exists that there may be unknown benefits to consuming levels of nutrients above those known to be needed for good health, it is not reasonable to make a program priority of this uncertain benefit when so many other known needs are present. According to data provided in the SUSTAIN report and elsewhere (Toole, 1994), scurvy is rarely seen in stable, free-living populations. Vitamin C is not among the high-priority micronutrients identified as a public health concern in less developed countries (OMNI, 1994). Even in emergency feeding situations, documented scurvy outbreaks are uncommon in refugee camps in Latin America and Asia; in Africa, the majority of reported outbreaks of scurvy have been in the Eastern Sahel (greater Horn of Africa and Kenya). Seventy-five percent of blended foods provided by the United States go to India (USAID, 1997a, b). All of this is used in development programs targeted

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--> primarily towards maternal and child health supplementary feeding. An additional 7 percent goes to development programs in Central and South America. Of the remaining 18 percent, much is distributed in development programs. On the assumption that half of this 18 percent goes to refugee feeding at most, it can be estimated that 9–10 percent of blended foods are distributed in refugee and emergency feeding programs. Not more than 70 percent of these applications are likely to be in East Africa, where scurvy has been reported. This means that only 7 percent of blended foods at most are distributed in situations where vitamin C deficiency might be a problem. TABLE 3-1. Possible Consequences of Added Cost from Higher Vitamin C Levels   CSB WSB Total Quantity purchased (MT) 238,300 11,310 249,610 Total cost ($) 79,768,542 5,184,617 84,953,159 Average cost ($/MT) 334.74 458.41 — Average cost ($/bag) 18.41 25.21 — Extra vitamin Cost ($/MT) 6.33 6.33 — Total extra cost ($) 1,508,439 71,592 1,580,031 Equivalent product (MT)a 4,506 156 — Fewer people/year at 30g/person/day 411,534 14,263 425,797 Cost of product reaching at risk individuals ($/MT)b Range: $90 to $3,610     a The amount of product that could not be distributed if the cost of the increase in vitamin C (from 40 to 90 mg) was subtracted from the total amount of funds available during FY 1996 to produce these commodities. b Based on assumptions that only 7 percent of blended foods reach refugee camps in East Africa, and the percentage of individuals in these camps who are at risk of deficiency was 25 percent and 10 percent. SOURCE: Adapted from Ranum and Chomé, 1997. Thus, fully 93 percent of the cost of adding more vitamin C to blended food as a strategy for avoiding scurvy would likely be unnecessary in nutritional terms. In monetary terms, the marginal cost to provide additional fortification of blended foods is $6.33/MT (Table 3-1). The marginal cost of fortifying blended foods likely to reach refugee populations in East Africa is $90.43/MT (27 percent of the current price). Since not all of this group is at risk, the cost per actual target beneficiary reached could be much higher. For example, if 25 percent of East African refugee camps are at high risk of deficiency, the marginal cost of reaching a target camp by fortifying all blended food with high levels of vitamin C is $361 per MT that actually reaches the target population. These high costs result from the inability to target fortified food to the at-risk population. If 10 percent of the at-risk population is actually deficient in vitamin C, the cost of reaching the deficient group is ten times this, or $3,610/MT. That is, based on these assumptions, to deliver one dollar's worth of vitamin C

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--> through fortified food to the target individual would require distribution of $40 worth of food: only one fourth ($10) reaches the high-risk camps, and of this only one tenth ($1) actually reaches the deficient individual. Alternative strategies that can target individuals with deficient vitamin C intake could be much more cost-effective, even if the cost per target individual were higher because the leakage to individuals not in need of the intervention would be lower. Our interest, however, is not so much in the cost per MT of food delivered to the target population, but in the cost per case of scurvy averted. To estimate this requires an estimate of the total size of the population at risk. Although the incidence of scurvy can be high in isolated instances, the total number of reported cases over the past 20 years is about 100,000 (Desenclos et al., 1989), or only 5,000 cases per year. It is likely that the incidence of scurvy is underreported, but doubling the incidence yields an estimate of only 10,000 cases per year, representing a very small proportion (0.06%) of the estimated 17 million refugees per year depending on food aid (Toole, 1992). At current levels of P.L. 480 distribution, the quantity of blended food going to refugees in camps is enough to provide a 30 g daily ration to 13% of the total number of refugees in camps, or 2.21 million people per year. This number represents more than 200 times the estimated scurvy incidence of 10,000 cases, although there is no assurance that normal distribution would necessarily target those individuals. Assumptions Regarding Nutrient Losses The SUSTAIN pilot study estimated losses of vitamin C from conventional and highly fortified blends. It showed losses of zero to 13 percent during transport and storage, which can be considered negligible. However, losses in cooking are much more significant. At high levels of fortification, retention of vitamin C after cooking CSB was between 48 percent and 67 percent (see Table 4-2). The higher figure was for blends fortified to a level of 170 mg/100 g, much higher than the highest level of fortification proposed, therefore that figure was not used in subsequent calculations. The lower figure was fairly consistent for blends fortified at around 100 mg/100 g, which is close to the proposed level of 90 mg/100 g. Therefore, the lower figure (48 percent) is used in these estimates. Retention of vitamin C in highly fortified WSB was lower, 32–33 percent (see Table 4-3). At conventional levels of fortification, CSB was estimated to retain 17 to 32 percent (average 24.5 percent) of vitamin C. Although these results are questionable, they are the best available empirical estimates. Conventionally fortified WSB retained about 18 percent of its vitamin C content. For purposes of these estimates, the figures for CSB are used, which represents more than 95 percent of the total blended food provided under P.L. 480.

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--> With these estimated retentions (24.5 and 48 percent), 100 g of CSB at conventional levels of fortification (40 mg/100 g), if fortified to target, provides 9.8 mg of vitamin C; 100 g of high-fortified CSB (90 mg/100 g) provides 43 mg of vitamin C. If blended foods are considered the only source of vitamin C, the cost of providing 10 mg of vitamin C with conventionally fortified CSB is 3.4 cents (range: 5 cents at 17 percent retention, 2.7 cents at 32 percent retention). With high-fortified CSB, 10 mg of vitamin C costs 0.79 cents. Highly fortified CSB is thus 4.3 times more cost-effective (range: 6.3 times at 17 percent retention, 3.4 times at 32 percent retention) as a delivery mechanism for vitamin C. A 30 g daily ration of blended food provides slightly less than 3 mg of vitamin C at conventional levels of fortification; at high levels, it would provide 12.9 mg, which would be sufficient to prevent scurvy. It would take 102 g of conventional CSB to provide 10 mg of vitamin C and 23 g of high-fortified CSB to provide the same amount. Recall, however, that 102 g of conventional CSB would also provide 388 calories, 18.7 g of protein, and additional quantities of other micronutrients, compared to only 87 calories, 4.2 g of protein, and comparably smaller amounts of other micronutrients in the highly fortified CSB. Because of methodological problems in estimating the loss of vitamin C during cooking, two alternative calculations are presented here, with uniform rates of nutrient retention assumed for both conventional and highly fortified CSB at 30 and 60 percent. At a vitamin C retention rate of 30 percent, the cost of providing 10 mg of vitamin C in conventionally fortified CSB is 2.79 cents, and in highly fortified CSB it is 1.26 cents. A 30 g daily ration of conventionally fortified CSB would provide 3.6 mg of vitamin C; the same ration of highly fortified CSB would provide 8.1 mg. To provide 10 mg of vitamin C would require 83.3 g of conventional CSB and 37 g of highly fortified CSB. At 60 percent retention, the cost of providing 10 mg of vitamin C would be 1.39 cents for conventional CSB and 0.63 cents for highly fortified CSB. The ration required to provide 10 mg of the vitamin would be 41.6 of conventional or 18.5 g of highly fortified CSB. A 30 g ration of conventional CSB would provide 7.2 mg of vitamin C; a 30 g ration of highly fortified CSB would provide 16.2 mg. However, we know that retention rates are higher when initial fortification levels are higher. If conventional CSB retains 30 percent of its fortificant and highly fortified CSB retains 60 percent, then providing 10 mg of vitamin C to an individual would cost 2.79 cents per day with conventional CSB and 0.63 cents per day with highly fortified CSB, suggesting that the highly fortified CSB may be as much as 4.4 times more cost effective as a vitamin C delivery mechanism Note, though, that the reduction in quantity of ration implicit in this calculation would have serious implications for other nutrients contained in the blended food. Even though 18.5 g of highly fortified CSB would be sufficient to provide 10 mg of vitamin C under these assumptions, such a small ration would provide very low levels of the other macro-and micronutrients in the food. This

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--> food, although intended as a supplementary ration, is still food; it should not be treated as if it were simply a vitamin C pill. Obviously, the rate of nutrient retention greatly affects the cost-effectiveness assessment. It is possible to generate a variety of alternative cost scenarios at various levels of retention. Although the best empirical information we have is used in the first set of estimates presented here, this information is limited because it comes from only two sites and from very few samples. Still, the conclusion is quite robust to alternative reasonable assumptions of nutrient retention. If only vitamin C consumption is considered and if blended foods are considered the only source, then highly fortified CSB is a more cost-effective delivery system than conventional CSB. If vitamin C consumption is considered in relation to the level of deficiency in the population, however, and other nutrient needs are also taken into account, this conclusion is not warranted. The results of the pilot suggest that even after transportation, storage, and cooking under the conditions observed in Haiti and Tanzania, there is still significant vitamin C left in the food. If simply delivering more vitamin C were the objective, then at reasonable estimates of nutrient retention, highly fortified CSB is a more cost effective mechanism for delivering vitamin C than conventional CSB. However, it is not more cost-effective for preventing scurvy. Appropriateness of Blended Foods as a Strategy for Reducing the Risk of Vitamin C Deficiency In most refugee situations, blended foods are not part of the general ration. Blended foods are provided in the general ration in situations where additional micronutrients are needed, for example, when access to local markets is cut off or when seasonal shortages occur. These foods are more often used as supplementary food in maternal and child health programs. When frank scurvy appears in refugee camps, distribution of blended foods is only one option considered; others include procurement of local foods containing vitamin C (a preferred strategy because such procurement can strengthen the local economy, the foods provide additional nutrients, and a quick response is possible) or provision of therapeutic doses through ascorbic acid tablet distribution. When blended foods are provided, WFP arranges to procure fortified blended foods from various suppliers (e.g., in Europe, South Africa) or to set up processing capacity for blended foods locally, using imported vitamin-mineral premixes. Some of these foods are fortified at higher levels than currently available P.L. 480 blended foods. The lag time for procuring blended foods from the United States if they have not routinely been provided is four to six months, too long for emergency response to an acute health problem. Although blended foods can forestall scurvy in at-risk camps that have no access to other sources of vitamin C-containing foods, different approaches are preferable under most circumstances.

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--> Cost of Additional Fortification The additional cost of raising the current fortification level of vitamin C from 40 to 90 mg/100 g is $6.33/MT of blended food (Table 3-1). These estimates are based on 1996 prices, which are considerably lower than prices from 1995; however, the price of vitamin C is expected to remain low for at least the next three years, due to the entry of China into the market as a producer of synthetic vitamin C (Ranum and Chomé, 1997). Since synthetic vitamin C is already purchased in bulk, there is no reason to expect that the price would fall further if the level of fortification were increased. The cost of a metric ton of blended food at current levels of fortification is $334.74 for CSB and $458.41 for WSB. The marginal cost of additional vitamin C fortification thus represents about 1.8 percent of the cost of CSB. The cost of vitamin C represents about one-third of total vitamin premix costs (see Appendix C). For purposes of estimating the cost-effectiveness of increasing vitamin C fortification of blended foods, one must assume that the target fortification levels are reached consistently at the costs given. At present, this assumption is not correct. For cost-effectiveness analysis of the intervention to be meaningful we must first verify that the intervention is technically achievable. (Technical intervention to ensure consistency is addressed separately in Chapter 6 of this report.) Ration Size The SUSTAIN report states that the expected daily ration of fortified, blended food per person is 30 g. OMNI (1994) gives an expected ration of 40 g. Other reports say that the expected ration may be as high as 90 per person per day or variable depending on need (T. Marchione, USAID, personal communication, June 1997). Planned distributions of CSB for fiscal year (FY) 1996 (USAID, 1996) are based on per-person daily rations ranging from 30 to 216 g. However, no information is available on quantities actually distributed or above all, on the reliability and consistency of distribution. Clearly, if blended foods are provided at conventional levels of fortification but in higher amounts than the assumed 30 g per day ration, the conventionally-fortified ration could forestall scurvy and provide additional nutrients. A ration of about 102 g of conventionally fortified blended food would provide 10 mg of vitamin C, based on the pessimistic assumption of 24.5 percent nutrient retention after cooking. Of the highly fortified food, 23 g would provide 10 mg of vitamin C under the optimistic assumption of 48 percent nutrient retention. (If 30 percent nutrient retention is assumed for both, the necessary ration would be 83.3 g for the conventional and 30 g for the highly fortified food.) Providing a larger quantity of blended food has the considerable added advantage of supplying more of all the other macro-and micronutrients in the food. Since scurvy occurs mainly in cases of extreme need where refugees are entirely

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--> dependent on often inadequate relief rations, the other nutrients in the blends are likely to be just as necessary. For example, recent surveys in long-standing refugee camps in Kenya, Ethiopia, and Somalia where scurvy had previously been reported, showed prevalence of wasting (an indicator of protein-energy malnutrition [PEM]) of over 50 percent in Ethiopia, and 20 to 40 percent in Kenya. Camps in Kenya also had a prevalence of anemia of 75 to 85 percent (AAC/SCN, 1997). Further, if the ration is already closer to 100 g than to 30 g, current levels of fortification should be sufficient to provide the 10 mg of vitamin C required to prevent scurvy. Cost-Effectiveness Because of lack of information about the prevalence of vitamin C deficiency, an accurate estimate of the cost per case of scurvy averted is impossible. About 100,000 cases of scurvy have been reported over the past two decades or about 5,000 cases per year (Desenclos et al., 1989, ). If the estimate is doubled and an incidence of 10,000 cases per year is assumed, and if all these cases could be averted simply by extra fortification, then the cost of averting a case of scurvy using extra fortification of CSB and WSB would be $158. Since at most 13 percent of refugees are reached by P.L. 480 blended foods (assuming a 30 g daily ration for a year), we may assume that at most only about 13 percent of scurvy cases could be averted using current allocations; if only 13 percent of the 10,000 cases per year could be averted through increased fortification, then the cost per case averted would be $1,223. At current prices, the cost of tripling the ration of conventionally fortified blended food from 30 to 90 g per person per day, an amount that would provide close to the 10 mg needed to prevent scurvy, would be an additional $7.45 per person per year, a total of $74,500 for 10,000 cases. Reported scurvy prevalence in high-risk camps ranges from 1 percent to as high as 45 percent for high risk subgroups (Magan et al., 1983, CDC, 1989; Desenclos et al., 1989; ACC/SCN, 1996). It would be virtually impossible to target rations narrowly only to potential scurvy sufferers inside the camps. If prevalence is about 20 percent, at most one fifth of the blended food would reach those who have scurvy or are likely to develop it, which would raise the cost per case averted or cured using conventionally fortified food to $37.25. If the prevalence were estimated at 10 percent (probably a more realistic estimate), the cost per case actually averted or cured would be $74.50. Thus even assuming that extra fortification could cure all cases of scurvy (using the estimate of 10,000 cases per year), tripling the conventional ration to high risk camps is more than twice as cost effective (cost-effectiveness ratio of 2.1) as fortifying the entire supply of blended food. If the proportion of cases that could be averted using extra fortification is the same as the proportion of refugees potentially covered by P.L. 480 blended food distribution (13 percent), then the ratio is 16.4: it would cost 16.4 times as much

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--> to avert a case of scurvy through extra fortification as through increasing the size of the conventional ration to beneficiaries in the target camps. To avert 10,000 cases of scurvy per year would require a total of 109.5 MT of blended food at high levels of fortification, given a ration of 30 g per day for 365 days a year at a retention level of 49 percent. This amount represents 0.045 percent of the total blended food that would be available if the current amounts distributed were adjusted downward to account for the cost of extra vitamin C. At conventional levels of fortification, a ration of 102 g per day would be required, or 372.3 MT—about 0.15 percent of the total amount currently available. Since extra fortification raises the cost of blended foods by 1.8 percent, tripling the conventional ration for 10,000 recipients, which would reduce the amount available by only 0.14 percent, clearly is over 12.8 times more cost effective. If the triple ration were targeted by camp rather than individual suffering from scurvy and a prevalence rate of 10 percent were assumed, tripling the conventional ration would reduce the total amount of blended food available by 1.4 percent, which is still less than the 1.8 percent cost of fortifying the entire supply of blended food. Once again, this calculation considers only the benefit of providing vitamin C without taking account of the additional nutrients that would be provided in a triple ration. Opportunity Cost An important element of cost-effectiveness is opportunity cost. At current prices for blended foods and vitamin C, raising the level of fortification of CSB and WSB would cost S $1,580,031, and would represent about 1.8 percent of the total cost of blended foods. If the budget for blended foods is fixed, raising the level of fortification of vitamin C in blended foods would reduce the total amount of blended food available by 186,499 metric tons, (1.8 percent; Ranum and Chomé, 1997). This quantity could provide a daily 30 g ration of conventionally fortified blended food to 425,797 people for a year and provide 114 kcal, 5–6 g of protein, and a wide range of micronutrients besides vitamin C to targeted vulnerable groups. Protein-energy malnutrition (PEM) and other micronutrient deficiencies (notably of vitamin A, iron, and iodine) are generally considered a higher public health priority than vitamin C deficiency, because of the larger numbers of people affected. This does not mean that the vitamin C currently provided in blended foods should be eliminated. There are rare cases in which refugees are entirely dependent on donated rations, with no possibility of trading with the outside or of producing their own food. In these cases, the vitamin C in blended food is necessary because it may well be the sole source. Higher fortification of U.S.-provided blended foods may not be the most efficient or cost-effective of these alternatives. Other approaches to improving vitamin C nutrition in refugee camps are likely to be more cost-effective. For instance, use of local food sources rich in vitamin C benefits the local economy and provides additional nutrients in the foods. Local foods can be obtained

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--> quickly, to respond to the need for vitamin C in a timely way. Alternative approaches for the prevention of scurvy should be explored in situations where the availability of vitamin C-rich foods is low. Iron Objective A secondary argument for providing additional vitamin C in blended food is that it enhances the absorption of iron; thus, it might be possible to reduce the amount of iron in blended food if additional vitamin C were provided. The current cost of fortifying blended foods with iron is $1.61/MT. If this level could be cut by half with the addition of vitamin C at proposed levels (which is probably an overestimate), the cost of iron fortification per metric ton would be reduced by 80 cents, whereas the cost of the additional vitamin C would be $6.33. Thus, the net effect of improving iron absorption through the addition of vitamin C would be an additional cost of $5.52 per metric ton; obviously, adding vitamin C is not a cost-effective strategy for improving the absorption of iron from blended foods. Although there are many approaches that could be considered to improve iron intake, this substantial difference in cost-effectiveness and the uncertainty about the stability of vitamin C make it unlikely that further comparisons would alter this conclusion. In fact, it may be better to replace the present form of iron used in blended foods with another form, since the present form is poorly absorbed and reduces vitamin C retention. A more complete cost-effectiveness analysis should consider other forms of iron, but this is beyond the scope of the committee's assignment. It seems most unlikely that such analysis would result in recommending an increase in vitamin C fortification to improve iron absorption.

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